Personal injury - auto accident questionnaire

PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE

TODAY’S DATE:
PERSONAL INFORMATION:
EMPLOYER:
SPOUSE'S NAME:
CHILDREN:
How many children are living with you now? IMPORTANT: How can we contact you at all times? (Relative or friend who can always locate you):
EDUCATION:
EMPLOYMENT HISTORY:
Prior similar injuries, treated medical conditions and/or symptoms
to same area or current injury (Dates/Drs.): Prior claims and/or settlements (types, dates, attorneys):
ACCIDENT INFORMATION:
DETAILS OF ACCIDENT:
Weather condition (if happened outside): DESCRIPTION OF ACCIDENT: (BE SPECIFIC—PROVIDE AS MUCH DETAIL AS POSSIBLE)
What was the make, model and year of the vehicle you were driving? What was the make, model and year of the other vehicle? Was anyone, including yourself, taking any medication or using drugs? Describe. Had anyone, including yourself, been drinking? Describe. Did anyone make a statement at the scene? IMPORTANT: (PROVIDE COPIES OF ALL PHOTOGRAPHS IN YOUR POSSESSION)
Were photographs taken of the scene? By whom? Were photographs taken of the vehicles? By whom? Were photographs taken of your injuries? By whom? INSURANCE COVERAGE FOR PLAINTIFF: (Please provide a copy of your “Declarations of Coverage”)
Are you covered under your employer's insurance? If so, provide company and agent, if known: IMPORTANT: Has anyone from an insurance company contacted you about this claim?
Name and phone of Person who contacted you: Did you give a statement to anyone? To whom? Have you signed any authorizations to release information to anyone? INSURANCE COVERAGE FOR DEFENDANT:
MEDICAL INFORMATION:
Were you injured in this accident? Describe: Did you go to the hospital? If so, name of hospital? X-Rays taken? Were you taken by ambulance? Are you under a doctor’s care now? If so, name of doctor? LIST ALL DOCTORS, CHIROPRACTORS, HOSPITALS, ETC. YOU HAVE SEEN FOR THIS ACCIDENT:
PRESCRIPTIONS: BRING IN ALL RECEIPTS, BILLS, PRESCRIPTION BOTTLES, ETC.
Name, address and phone of pharmacy where prescriptions filled? Was anyone else injured?
NAME AND ADDRESS OF ALL PARTIES INVOLVED, INCLUDING AUTO PASSENGERS:
WITNESSES:
Relationship (fellow employees, supervisors, bystanders, etc.): Would they be willing to testify in court to what he/she saw? Relationship (fellow employees, supervisors, bystanders, etc.): Would they be willing to testify in court to what he/she saw? Relationship (fellow employees, supervisors, bystanders, etc.): Would they be willing to testify in court to what he/she saw? DAMAGES:
How have your injuries changed your lifestyle: Describe any pain and suffering that you’ve experienced? Loss of consortium (relationship with spouse, children, others): How do you feel you have been damaged emotionally by these injuries? How do you feel you have been damaged financially by these injuries?
PROPERTY DAMAGE
Was your vehicle repaired? _____________ Where were the repairs performed? What was the monetary amount of the damage to your vehicle? $___________________________________
IMPORTANT: Please provide any repair receipts or damage estimates

How were you referred to this office? ______________________________________________________
If an individual referred you, provide their name, address and telephone so we can thank them:
If you found us via the Internet, which search engine or directory did you use? (Google, Yahoo, Yahoo Yellow Pages, AOL Yellow Pages, FindLaw, etc.): What search terms did you use to locate our website? _________________________________ Is there anything else that you would like to discuss or that you believe we should know about you or your ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ PLEASE DIAGRAM HOW THE ACCIDENT OCCURRED (diagram lanes, locations of vehicles, etc):

Source: http://www.fisherlawgrouptennessee.com/forms/01.%20MVA%20Questionnaire.pdf